Compound angle laparoscopic methods and devices

ABSTRACT

Methods and devices are provided for performing minimally invasive surgical procedures. In one embodiment, a surgical device is provided that include an elongate shaft having a distal portion configured to be movable between a first configuration in which the distal portion of the shaft is substantially straight or linear and a second configuration in which the distal portion of the shaft is articulated at a compound angle. The shaft&#39;s distal portion can include two articulation joints to facilitate formation of the compound angle.

CROSS REFERENCE TO RELATED APPLICATIONS

The present application is a continuation of U.S. application Ser. No.14/032,747, filed Sep. 20, 2013, and entitled “Compound AngleLaparoscopic Methods and Devices,” which is a continuation of U.S.application Ser. No. 12/775,724, filed May 7, 2010 (now U.S. Pat. No.8,562,592) and entitled “Compound Angle Laparoscopic Methods andDevices,” which are hereby incorporated by reference in theirentireties.

FIELD OF THE INVENTION

The present invention relates to methods and devices for performingminimally invasive surgical procedures.

BACKGROUND OF THE INVENTION

Many surgical procedures involve inserting various instruments throughthe working channel of a surgical access device. The instruments areused to view, engage, and/or treat tissue within a body cavity or othersurgical site to achieve a diagnostic or therapeutic effect. Inlaparoscopic abdominal procedures for example, the abdominal cavity isgenerally insufflated with CO₂ gas to a pressure of around 15 mm Hg. Theabdominal wall is pierced and a plurality of tubular cannulas, eachdefining a working channel, are inserted at various points into theabdominal cavity. A laparoscopic telescope connected to an operatingroom monitor can be used to visualize the operative field and can beplaced through one of the cannulas. Other laparoscopic instruments suchas graspers, dissectors, scissors, retractors, etc. can be placedthrough the other cannula(s) to facilitate various manipulations by thesurgeon. In this type of procedure, because of the positioning of thecannulas, it can be relatively easy to “triangulate” the tips of twoseparate instruments, e.g., bring the tips together at a single pointwithin the abdominal cavity. For example, a first instrument could bepassed through a cannula in the left side of the patient's abdomen andoperated with the surgeon's left hand while a second instrument could bepassed through another cannula in the right side of the patient'sabdomen and operated with the surgeon's right hand. The surgeon can theneasily bring the tips of the two instruments together at an internalpoint, e.g. in the center of the patient's abdomen. A laparoscopeviewing instrument can also be passed through a third cannula,positioned for example in the center of the patient's abdomen, such thatthe tips of the two instruments can be easily visualized from above.

In other surgical procedures, however, visualization and triangulationis not as straightforward. For example, in Single Incision LaparoscopicSurgery (SILS) or Single Site Laparoscopic Surgery (SSLS), a singlelaparoscopic entry point is formed, e.g., through the navel. An accessdevice having one or more working channels, and typically a plurality ofworking channels, is then installed in the entry point and allinstruments required for performing the surgery are inserted throughthis same access device. In such procedures, the elongate shafts of thevarious instruments end up being generally parallel to one another whileinserted through the access device. This can make it very difficult totriangulate the tips of two instruments within the abdominal cavity,especially if the instruments do not have distal articulationcapabilities. In addition, since the viewing scope is inserted generallyalong the same axis as the various other instruments, it can bedifficult or impossible to see the tips of the instruments. Furthermore,the handles of the various instruments often end up being positioned inclose proximity to one another and create a so-called “chopstick”effect, which describes interference between the surgeon's hands,between the surgeon's hands and the instruments, and between theinstruments. Interference between the handles and/or the positioning ofthe handles can limit maneuverability and/or lead to discomfort for thesurgeon. These problems can unduly lengthen the duration of the surgery,potentially increasing the risk of patient complications. Also, in caseswhere it is impossible to achieve adequate triangulation and/orvisualization, a second or even third entry point must be formed,increasing trauma to the patient and creating additional scars.

Even in multiple-incision procedures or where triangulation andvisualization is possible (e.g., where one or more of the devicesincludes a distal articulation capability), triangulation,visualization, comfort, and maneuverability can still be sub-optimal.

Accordingly, there is a need for methods and devices which allowlaparoscopic procedures to be performed with an enhanced ability totriangulate and visualize surgical instruments and with improved surgeoncomfort and instrument maneuverability.

SUMMARY OF THE INVENTION

The present invention generally provides methods and devices forperforming minimally invasive surgical procedures. In one embodiment, anarticulating laparoscopic access device is provided that includes anelongate shaft, first and second linkages, and a linkage bar. The firstand second linkages and the linkage bar each have proximal and distalends. The proximal end of the first linkage is pivotally coupled to thedistal end of the elongate shaft at a first pivot point. The proximalend of the linkage bar is pivotally coupled to the distal end of thefirst linkage by a second pivot point, and the distal end of the linkagebar is pivotally coupled to the proximal end of the second linkage by athird pivot point. A first range of motion of the linkage bar about thethird pivot point is less than a second range of motion of the linkagebar about the second pivot point. The distal end of the first linkage,the proximal end of the second linkage, and the linkage bar are movablebetween a first position longitudinally aligned with a longitudinal axisof the elongate shaft and a second position displaced from thelongitudinal axis of the elongate shaft.

The device can include an actuator. The distal end of the second linkagecan be pivotally coupled to the actuator at a fourth pivot point. Theactuator can be movable longitudinally relative to the elongate shaft tolongitudinally move the distal end of the second linkage.

The linkages and the linkage bar can have a variety of configurationsand be coupled together in a variety of ways. For example, the proximalend of the linkage bar can be seated within a first groove formed in thedistal end of the first linkage, and the distal end of the linkage barcan be seated within a second groove formed in the proximal end of thesecond linkage. The first groove can define the first range of motion,and the second groove can define the second range of motion. For anotherexample, the elongate shaft, the first linkage, and the second linkagecan have an inner lumen extending longitudinally therethrough forreceiving a tool.

An end effector can be coupled to the distal end of the second linkage.The end effector can have a variety of configurations, but in oneembodiment, it can include opposed jaws. The device can include anactuator configured to move the opposed jaws between a closed positionand an open position. The actuator can extend through the elongateshaft, the first linkage, and the second linkage and be coupled to aproximal end of the opposed jaws.

In another aspect, a laparoscopic system is provided that includes anarticulation device and a tool. The articulation device has an elongateshaft, a first linkage coupled to the elongate shaft at a first joint,and a second linkage coupled to the first linkage at a second joint. Thesecond joint is movable radially outward relative to an axis extendinglongitudinally along the elongate shaft, and a distal end of the secondlinkage is constrained to longitudinal movement along the axis. The toolhas a flexible elongate shaft with an end effector on a distal endthereof. The flexible elongate shaft is disposable through a lumenextending through the elongate shaft, the first linkage, and the secondlinkage such that the end effector extends from the distal end of thesecond linkage. The flexible elongate shaft is bendable to conform to ashape of the lumen as the second joint is moved radially outward.

The system can include an actuator extending along the elongate shaftand having a distal end coupled to the distal end of the second linkage.The actuator can be longitudinally movable relative to the axis to movethe distal end of the second linkage along the axis. The distal end ofthe actuator can be coupled to the distal end of the second linkage at apivot point such that the second linkage is configured to pivot aboutthe pivot point relative to the actuator. In some embodiments, theactuator is rigid. The system can optionally include a lock configuredto lock the actuator in a fixed position relative to the shaft and thefirst and second linkages.

The first and second joints can be configured in any number of ways. Forexample, the first joint can include a pivot point formed between adistal end of the elongate shaft and a proximal end of the firstlinkage, and/or the second joint can include a linkage bar having aproximal end pivotally coupled to a distal end of the first linkage at afirst pivot point and a distal end pivotally coupled to a proximal endof the second linkage at a second pivot point. For another example, theend effector can be angularly oriented relative to the axis when thesecond joint is disposed radially outward from the axis.

In yet another aspect, a method for laparoscopic surgery is providedthat includes inserting a first tool through a first port formed in ahousing disposed within tissue to position a distal end of the firsttool within a body cavity, inserting a second tool through a second portformed in the housing to position a distal end of the second tool withinthe body cavity, inserting a flexible elongate shaft through a lumen ofone of the first and second tools, actuating the first tool to cause adistal portion of the first tool disposed within the body cavity to forma compound angle, and actuating the second tool to cause a distalportion of the second tool disposed within the body cavity to form acompound angle. The flexible elongate shaft bends to conform to a shapeof the lumen with the distal portion of the one of the first and secondtools. When proximal portions of each of the first and second tools aresubstantially parallel, actuating the first and second tools causes endeffectors at the distal ends of the first and second tools to beoriented toward one another without causing the distal portions of thefirst and second tools to intersect. In some embodiments, actuating thefirst tool can include longitudinally moving a first actuator extendingalong a first elongate shaft of the first tool, and actuating the secondtool can include longitudinally moving a second actuator extending alonga second elongate shaft. The method can optionally include engaging alock of at least one of the first and second tools to maintain thecompound angle of the one of the first and second tools in a fixedposition.

The end effector can have a variety of configurations. In someembodiments, the method can include actuating the first tool to moveopposed jaws of the end effector of the first tool between a closedposition and an open position, wherein the formed compound angle of thefirst tool remains fixed during actuation of the first tool.

BRIEF DESCRIPTION OF THE DRAWINGS

The invention will be more fully understood from the following detaileddescription taken in conjunction with the accompanying drawings, inwhich:

FIG. 1 is a perspective view of one embodiment of a laparoscopic deviceincluding a handle and an articulatable shaft extending distally fromthe handle, the shaft being in a straight configuration;

FIG. 2A is a perspective view of the articulatable shaft of FIG. 1showing the shaft in an articulated configuration;

FIG. 2B is a perspective view of the device of FIG. 1 showing an innershaft having an end effector coupled to a distal end thereof with thearticulatable shaft omitted for clarity;

FIG. 3 is a side view of the device of FIG. 1;

FIG. 4 is a cross-sectional side view of the device of FIG. 3;

FIG. 5 is a perspective view of a distal portion of the shaft of thedevice of FIG. 1;

FIG. 6 is another perspective view of a distal portion of the shaft ofthe device of FIG. 1;

FIG. 7 is a cross-sectional perspective view of the shaft of the deviceof FIG. 1;

FIG. 8 is a side, partially transparent view of a distal portion of thedevice of FIG. 1 with the end effector shown;

FIG. 9 is a side view of a distal portion of the shaft of the device ofFIG. 1;

FIG. 10 is a partial, cross-sectional view of the handle and the shaftof the device of FIG. 1;

FIG. 11 is a cross-sectional view of the handle of the device of FIG. 1;

FIG. 12 is a perspective view of one embodiment of a laparoscopic deviceincluding a handle and a cannulated articulatable shaft extendingdistally from the handle, the shaft being in a straight configuration;

FIG. 13 is a perspective view of one embodiment of a laparoscopic deviceincluding a handle and an articulatable shaft extending distally fromthe handle, the shaft being in an articulated configuration and havingan end effector coupled to a distal end thereof;

FIG. 14 is a perspective view of a distal portion of the device of FIG.13;

FIG. 15 is a perspective, partially cross-sectional view of a surgicalaccess device positioned within a tissue opening and having twolaparoscopic devices and a scoping device inserted therethrough andpositioned within a body cavity, the laparoscopic devices each having ashaft in an articulated configuration; and

FIG. 16 is a side view of distal portions of the laparoscopic devicesand the scoping device of FIG. 15 positioned in the body cavity.

DETAILED DESCRIPTION OF THE INVENTION

Certain exemplary embodiments will now be described to provide anoverall understanding of the principles of the structure, function,manufacture, and use of the devices and methods disclosed herein. One ormore examples of these embodiments are illustrated in the accompanyingdrawings. Those skilled in the art will understand that the devices andmethods specifically described herein and illustrated in theaccompanying drawings are non-limiting exemplary embodiments and thatthe scope of the present invention is defined solely by the claims. Thefeatures illustrated or described in connection with one exemplaryembodiment may be combined with the features of other embodiments. Suchmodifications and variations are intended to be included within thescope of the present invention.

Various exemplary devices and methods are provided for performingminimally invasive surgical procedures. In general, the devices andmethods allow a shaft of a surgical instrument to form a compound angle,thereby facilitating optimal positioning of a working distal end of theinstrument relative to a surgical site. In an exemplary embodiment, alaparoscopic device includes an elongate shaft having a distal portionconfigured to be movable between a first configuration in which thedistal portion of the shaft is substantially straight or linear and asecond configuration in which the distal portion of the shaft is bent ata compound angle. In an exemplary embodiment, the shaft's distal portioncan include two articulation joints to facilitate formation of thecompound angle. The shaft's distal portion can be configured to bearticulated in a wide range of compound angles. The shaft's distalportion can also be configured to be locked in a fixed articulatedposition, thereby allowing the device to be easily held in a desiredbent position. The device can thus be inserted into a patient's bodywith the shaft in the first configuration, and it can be subsequentlymanipulated to move the shaft from the first configuration to the secondconfiguration to allow the device's working distal end, e.g., an endeffector, to be optimally angled within the body relative to a surgicalsite and/or any other surgical instruments at the surgical site. Theshaft can also be configured to move from the second configuration tothe first configuration to ease removal of the device from the patient.Such a configuration can be particularly advantageous where two or moreinstruments are inserted into a patient's body cavity through the sameentry port in tissue because it can allow for triangulation. Inparticular, distal tips of the instruments can be brought together at asingle point within the body cavity, even though the instruments' shaftsextend generally parallel to one another.

A person skilled in the art will appreciate that while the methods anddevices are described in connection with laparoscopic procedures inwhich one or more surgical instruments are inserted into a patient'sbody through an artificial opening, e.g., an incision, the methods anddevices disclosed herein can be used in numerous surgical procedures andwith numerous surgical instruments. By way of non-limiting example, themethods and devices can be used in open surgical procedures.

A person skilled in the art will also appreciate that the devicesdisclosed herein can be inserted into a body in any way, such as througha natural orifice, through an incision or puncture hole formed intissue, etc. The devices can be inserted directly into a patient's bodyor can be inserted through an access device having a working channelthrough which a shaft of a surgical instrument can be advanced. A personskilled in the art will further appreciate that an access device can beconfigured to allow insertion of a single surgical instrumenttherethrough, such as with a straight cannula, or to allow simultaneousinsertion of multiple instruments therethrough, such as with a surgicalaccess device having multiple sealing ports each defining a workingchannel. Devices disclosed herein can alternatively or additionally beintroduced into a body through an auxiliary passageway along the outsideof a scoping device or other surgical instrument, as will be appreciatedby a person skilled in the art. Exemplary embodiments of a surgicalinstrument that provides such an auxiliary passageway are described inmore detail in U.S. Pat. No. 7,615,005 issued Nov. 10, 2009 entitled“Medical Apparatus For Use With An Endoscope,” which is herebyincorporated by reference in its entirety.

In an exemplary embodiment, shown in FIGS. 1-4, a surgical device 10 isprovided that includes a proximal handle 12 having a shaft assembly 20surrounding an elongate shaft 36 extending distally therefrom. The shaft36 can have a working element or end effector 22, generally referred toas an “end effector,” at a distal end thereof. As shown in FIGS. 2A and2B, the device 10 in the illustrated embodiment includes the shaftassembly 20 and a tool 19 including the shaft 36 releasably receivablewithin the shaft assembly 20 such that the end effector 22 at a distalend of the shaft 36 can extend distally beyond a distal end 20 d of theshaft assembly 20. As discussed further below, articulation of the shaftassembly 20 can articulate a distal portion 36 a of the shaft 36.Although the shaft assembly 20 and the tool 19 can be separate units asin the illustrated embodiment, the shaft assembly 20 and the tool 19 canbe integrally formed, as also discussed further below. The end effector22 is omitted from FIGS. 1, 3, and 4 for clarity. The end effector 22 inthe illustrated embodiment includes a tissue grasper having a pair ofopposed jaws 16 a, 16 b configured to move between open and closedpositions, but as will be appreciated by a person skilled in the art theend effector 22 can include any tool, e.g., a grasper, a dissector,scissors, forceps, a retractor, a light, etc. As discussed furtherbelow, the handle 12 can be configured to operate the end effector 22,and a control knob 28 at a location distal of the handle 12 can beconfigured to facilitate articulation and/or rotation of at least aportion of the shaft assembly 20.

The shaft assembly 20 can have a variety of sizes, shapes, andconfigurations. The shaft assembly 20 can be rigid, flexible, or acombination thereof. Portions of the shaft assembly 20 can be lessflexible or more rigid than a remainder of the shaft assembly 20 tofacilitate insertion through tissue and/or operation of the end effector22. As in the illustrated embodiment, the distal portion 36 a of theshaft 36 can be flexible, and a remainder of the tool 19, as well as theshaft assembly 20, can be rigid. Having a rigid shaft assembly 20 and ashaft 36 rigid along a substantial longitudinal length thereof can helpfacilitate translation of forces in articulating and actuating thedevice 10 as discussed further below.

As mentioned above, the shaft assembly 20 can be tubular, and it canhave an inner lumen 34 extending therethrough, as shown in FIG. 4, whichcan receive the shaft 36. A person skilled in the art will alsoappreciate that although the inner lumen 34 in the illustratedembodiment extends along a longitudinal axis of the shaft assembly 20through the shaft assembly 20 and the handle 12, the inner lumen 34 canbe at least partially radially/laterally offset from the shaft'slongitudinal axis 20A, extend through the shaft assembly 20 and only aportion of the handle 12, and/or extend only through a portion of theshaft assembly 20. The device's inner lumen 34 can be configured toslidably receive the shaft 36 such that when the shaft 25 extendsthrough the device's articulation assembly 18, articulation of thearticulation assembly 18 can correspondingly articulate the shaft 36 atthe flexible portion 36 a thereof in a compound angle and thusfacilitate optimal positioning of the end effector 22. The tool's handleand/or a portion of the tool's shaft 36 can be configured to lock toshaft assembly 20, e.g., with a J-lock, spring-loaded detent, etc., tohelp prevent unintentional movement of the end effector 22 when it isoptimally positioned relative to the device's shaft assembly 20.

The shaft assembly 20 can have any longitudinal length, although in anexemplary embodiment it is long enough to allow the handle 12 and thecontrol knob 28 to be manipulated outside a patient's body when thedevice 10 is partially inserted into the body with the end effector 22disposed within a body cavity, e.g., have a longitudinal length of about33 cm. In this way, the shaft assembly 20 and the end effector 22 can beeasily manipulated when the device 10 is in use during a surgicalprocedure. The shaft assembly 20 can have any diameter D, e.g., lessthan or equal to about 10 mm, and more particularly less than or equalto about 5 mm, to allow for insertion of the shaft assembly 20 throughan access device, such as during a laparoscopic surgical procedure. Theend effector 22 coupled to the shaft's distal end can have a diameterequal to or less than the shaft's diameter D, at least when the jaws 16a, 16 b are in a closed position, to further facilitate insertion of thedevice's distal portion into a patient's body.

In an exemplary embodiment, the shaft assembly 20 can be substantiallycylindrical to help the shaft assembly 20 pass smoothly into a body. Theshaft assembly 20 can have any constant or varying shape along itslongitudinal length, and the shaft's diameter D can be uniform ornon-uniform along its longitudinal length. In an exemplary embodiment,as shown in FIGS. 3 and 4, the shaft assembly 20 can have asubstantially uniform diameter D along its longitudinal length except atone or both of the articulation joints 42, 44, which can have diametersthat differ from the shaft's diameter D, as discussed further below.

Generally, the shaft assembly 20 can include an articulation assembly 18surrounding at least the distal portion 36 a of the shaft 36 when theshaft 36 is received within the shaft assembly 20. The articulationassembly 18 can be movable relative to the shaft 36 to articulate thedistal portion of the shaft assembly 20 and the distal portion 36 a ofthe shaft 36 received therein and generally aligned with thearticulation assembly 18. Generally, the articulation assembly 18 can beconfigured to be movable between a linear or straight configuration,generally referred to as a “straight configuration,” in which thearticulation assembly 18 extends substantially parallel to alongitudinal axis 20A of the shaft assembly 20, as illustrated in FIGS.2-4, and an articulated, bent, or compound angle configuration,generally referred to as an “articulated configuration,” in whichportions of the articulation assembly 18 do not extend parallel to thelongitudinal axis 20A, as illustrated in FIG. 1. In the illustratedexemplary embodiment, the articulation assembly 18 is biased to thestraight configuration, e.g., in a configuration with the knob 28 sliddistally because of a tendency of the shaft's distal portion 36 a toreturn to a straight or linear configuration. As will be appreciated bya person skilled in the art, the articulation assembly 18 can be biasedin any other way, e.g., using a shape memory material, it can beunbiased, or it can be biased to the articulated configuration. Althoughthe articulation assembly 18 can be located anywhere along the shaftassembly 20, e.g., positioned at a mid-portion thereof, as shown in theillustrated embodiment, it can be located in a distal portion thereofsuch that a distal portion of the device 10 can be configured toarticulate to form a compound angle. Similarly, the flexible distalportion 36 a of the shaft 36 can be located anywhere along the shaft 36,as in the illustrated embodiment, it can be located in a distal portionthereof. Although the shaft assembly 20 can be configured to bend anynumber of times to form a compound angle, the articulation assembly 18in the illustrated embodiment is articulated at first and secondarticulation joints 42, 44 to form a triangulated compound angle, asdiscussed in further detail below.

The articulation assembly 18 can have a variety of sizes, shapes, andconfigurations. Generally, it can include a plurality of sections,segments, or linkages, generally referred to as “linkages,” along theshaft's longitudinal length to facilitate articulation of the shaftassembly 20. As shown in the embodiment illustrated in FIGS. 1-11, thearticulation assembly 18 can include a proximal elongate shaft 24, afirst linkage 26 coupled to a distal end of the proximal shaft 24, and asecond linkage 30 coupled to a distal end of the first linkage 30. Thefirst and second linkages 26, 30 can be coupled together with at leastone bar or rod, generally referred to as a “linkage bar” located betweenthe first and second linkages 26, 30. In the illustrated embodiment, thearticulation assembly 18 includes identical first and second linkagebars 32 a, 32 b on opposite sides of the shaft assembly 20, e.g.,separated about 180° from one another around the shaft's circumference.While two shaft linkages are illustrated in the embodiment of FIGS.1-11, a person skilled in the art will appreciate that in otherembodiments, the device can include any number of linkages.

As shown in FIG. 8, when the articulation assembly 18 is in thearticulated configuration, and the tool 19 is inserted therein such thatthe end effector 22 extends distally beyond the assembly's distal end 20d, the end effector 22 can be configured to be oriented transverse to,and optionally to intersect or “cross,” the shaft's longitudinal axis20A, which can facilitate optimal positioning of the end effector 22relative to other devices and/or a surgical site, and which can reduce a“chopstick” effect between the device 10 and any other adjacent surgicalinstruments. Depending on the size of the first and second linkages 26,30 and on the amount the articulation assembly 18 is articulated, thedistal portion of second linkage 30 can also intersect or “cross” theshaft's longitudinal axis 20A.

The proximal shaft 24 and the linkages 26, 30 can have a variety ofsizes, shapes, and configurations. For example, the proximal shaft 24and the linkages 26, 30 can each be in the form of a relatively rigidtubular section, e.g., made from a generally non-bendable material suchas a hard polymer or titanium, with the inner lumen 34 extendingtherethrough. As shown in FIGS. 3 and 4 of the illustrated embodiment,the proximal shaft 24 can have a longer longitudinal length 24L than thefirst and second linkages 26, 30 alone or together. Also as in theillustrated embodiment, a longitudinal length 26L of the first linkage26 can be longer than a longitudinal length 30L of the second linkage30. Alternatively, the longitudinal length 30L of the second linkage 30can be larger than the longitudinal length 26L of the first linkage 26,or the first and second linkages 26, 30 can have substantially equallongitudinal lengths 26L, 30L.

As shown in FIGS. 2-4, a proximal portion of the shaft 36 can bedisposed within the handle 12 with a remainder of the shaft 36 extendingdistally from the handle 12 in a generally straight line parallel to theshaft's longitudinal axis 20A. The distal portion of the shaft 36 can beat least partially received in the inner lumen 34 and surrounded by theproximal shaft 24, which can be slidable around and relative to theshaft 36 to facilitate articulation at the articulation joints 42, 44,as discussed further below.

The articulation assembly 18 can be configured to facilitate smooth andcontrolled articulation of the shaft assembly 20 relative to the handle12 with the first articulation joint 42 being located between theproximal shaft 24 and the first linkage 26 to allow the proximal shaft24 and the first linkage 26 to be angled relative to one another, andwith the second articulation joint 44 being located between the firstand second linkages 26, 30 to allow the first and second linkages 26, 30to be angled relative to one another offset from the shaft'slongitudinal axis 20A. The proximal shaft 24 and the linkages 26, 30 canthus be configured to articulate to form a compound angle. The proximalshaft 24 can be configured to be in a fixed position along the shaft'slongitudinal axis 20A when the articulation assembly 18 is in thestraight configuration, as shown in FIGS. 1 and 3-6, and in thearticulated configuration, as shown in FIG. 8. In contrast, the firstand second linkages 26, 30 and the linkage bars 32 a, 32 b can beconfigured to be longitudinally aligned with the shaft's longitudinalaxis 20A when the articulation assembly 28 is in the straightconfiguration, as shown in FIGS. 1, 3-7, and 9, and the first and secondlinkages 26, 30 can be angularly oriented relative to the shaft'slongitudinal axis 20A with the linkage bars 32 a, 32 b positioned awayfrom the axis 20A when the articulation assembly 18 is in thearticulated configuration, as shown in FIG. 8. As mentioned above, theend effector 22 can be coupled to a distal end of the shaft assembly 20such that the end effector 22 is positioned distal to the articulationjoints 42, 44. This can allow the end effector 22 to articulate with thearticulation assembly 18 and thereby be angularly oriented relative tothe shaft's longitudinal axis 20A in coordination with the secondlinkage 30, as illustrated in FIG. 8. In this way, the shaft assembly 20can be inserted into a patient's body, and the distal portion thereofcan be articulated inside the body without altering the angular positionof the proximal portion of the shaft assembly 20, e.g., the proximalshaft 24, that extends through an opening in the body, either directlyor through an access device. The end effector 22 can thus be oriented toextend toward and in a facing relationship with the longitudinal axis20A.

With the articulation assembly 18 in the articulated configuration, acompound angle is formed, with the respective axes 20A, 26A, 30A of theproximal shaft 24 and the linkages 26, 30 intersecting one another. Theaxes 20A, 26A, 30A can, however, all lie within a common plane.

The proximal shaft 24 and the linkages 26, 30 can be coupled together ina variety of ways. As illustrated in the embodiment of FIGS. 5-9, adistal end of the proximal shaft 24 can be pivotably coupled to aproximal end of the first linkage 26 at a first pivot point 38 to formthe first articulation joint 42. The first linkage 26 can thereby beconfigured to pivot or rotate, as shown in FIG. 8, relative to theproximal shaft 24 and the handle 12 about the first pivot point 38,which can have an axis that is generally perpendicular to thelongitudinal axis 20A of the proximal shaft 24. The proximal end of thefirst linkage 26 can thus be in a fixed position relative to the shaft'slongitudinal axis 20A, and the distal end of the first linkage 26 can befree to move radially inward toward and outward away from the shaft'slongitudinal axis 20A. The first and second linkages 26, 30 can also beconnected together in a pivotal relationship, via the linkage bars 32 a,32 b, to form the second articulation joint 44. A distal end of thefirst linkage 26 can be pivotally coupled to proximal ends of each ofthe linkage bars 32 a, 32 b at a second pivot point 40 at the secondarticulation joint 44, and a proximal end of the second linkage 30 canbe pivotally coupled to distal ends of each of the linkage bars 32 a, 32b at a third pivot point 46 at the second articulation joint 44. Thefirst linkage 26 can thereby be configured to pivot or rotate relativeto the second linkage 30, the proximal shaft 24, and the handle 12 aboutthe second pivot point 40, and the second linkage 30 can thereby beconfigured to pivot or rotate relative to the first linkage 26, theproximal shaft 24, and the handle 12 about the third pivot point 46. Thesecond and third pivot points 40, 46 can each have an axis that isgenerally perpendicular to the longitudinal axis 20A of the proximalshaft 24. In this way, the first and second linkages 26, 30 can botharticulate on a same side of the shaft assembly 20, e.g., on a same siderelative to the proximal shaft 24, to allow the end effector 22 tointersect or “cross” the shaft's longitudinal axis 20A. In other words,a longitudinal axis 26A of the first linkage 26 and a longitudinal axis30A of the second linkage 30 and the end effector 22 can be parallel tothe longitudinal axis 20A of the proximal shaft 24 when the articulationassembly 18 is in the straight configuration, as shown in FIGS. 3 and 4.When the articulation assembly 18 is in the articulated configuration,the longitudinal axes 26A, 30A of the first and second linkages 26, 30can be transverse relative to the shaft's longitudinal axis 20A at firstand second angles A1, A2, respectively, to angularly orient the endeffector 22. The first and second linkages 26, 30 can be configured tobe angularly oriented such that their longitudinal axes 26A, 30A can besubstantially perpendicular to one another. The measure of the first andsecond angles A1, A2 can depend, at least in part, upon the sizes andshapes of the proximal shaft 24, the linkages 26, 30, and the linkagebars 32 a, 32 b. The angles A1, A2 each being substantially at 0°correspond to the articulation assembly 18 being in the straightconfiguration. The second and third pivot points 40, 46, can be offsetfrom and positioned a distance apart from the linkages' longitudinalaxes 26A, 30A taken along a cross-section of the linkages 26, 30, e.g.,offset from center. Such offset pivot point(s) can help guide the firstand second linkages 26, 30 in desired articulated directions at thesecond articulation joint 44.

The proximal shaft 24, the linkages 26, 30, and the linkage bars 32 a,32 b can be pivotally coupled together in any way at their associatedones of the pivot points 38, 40, 46, as will be appreciated by a personskilled in the art. As in the illustrated embodiment shown in FIGS. 5-9,a first pin 50 can be inserted, e.g., by press fit, through respectivefirst holes 52 formed in the distal end of the proximal shaft 24 and theproximal end of the first linkage 26 to form a pivot hinge-type joint atthe first pivot point 38 between the adjacent proximal shaft 24 andfirst linkage 26. Similarly, second and third pins 54, 56 can berespectively inserted through second and third holes 58, 60 to pivotallycouple the linkage bars 32 a, 32 b to the first and second linkages 26,30 at, respectively, the second and third pivot points 40, 46.

The first and second linkages 26, 30 can respectively includes groovesformed therein at the second and third pivot points 40, 46 that can beconfigured to seat the linkage bars 32 a, 32 b. By seating the linkagebars 32 a, 32 b, the grooves can be configured to help reduce thediameter of the device's distal portion including the linkage bars 32 a,32, which can help ease insertion and removal of the device's distalportion to and from a patient's body. However, as in the illustratedembodiment, the linkage bars 32 a, 32 b can be configured to not beseated flush or sub-flush within the grooves but instead can extendlaterally/radially outward from outer surfaces of the first and secondlinkages 26, 30 such that the shaft's diameter D is larger at the secondarticulation joint 44 than elsewhere along the shaft's longitudinallength. In one embodiment, the grooves can be configured to defineranges of motion about the second and third pivot points 40, 46.

First and second grooves 62 a, 64 a seating the first linkage bar 32 a,shown in FIGS. 5 and 9, are discussed below in more detail, but as willbe appreciated by a person skilled in the art, third and fourth grooves62 b, 64 b seating the second linkage bar 32 b, shown in FIG. 6, on anopposite side of the shaft assembly 20 can be similarly configured. Thefirst groove 62 a formed in the distal end of the first linkage 26 canbe configured to seat the proximal end of the first linkage bar 32 a,and the second groove 64 a formed in the proximal end of the secondlinkage 30 can be configured to seat the distal end of the first linkagebar 32 a. The first and second grooves 62 a, 64 a can have any size andshape that allow the respective proximal and distal ends of the firstlinkage bar 32 a to be seated therein. In an exemplary embodiment, amaximum width W1 of the first groove 62 a can be larger than a maximumwidth W2 of the second groove 64 a, where the widths W1, W2 are measuredperpendicular to the shaft's longitudinal axis 20A when the articulationassembly 18 is in the straight configuration, as illustrated in FIG. 9.Such relative sizing of the first and second grooves 62 a, 64 a canallow the first linkage bar 32 a to have a first range of motion aboutthe second pivot point 40 located within the first groove 62 a that ismore than a second range of motion of the first linkage bar 32 a aboutthe third pivot point 46 located within the second groove 64 a. In thisway, the first linkage bar 32 a can be free to move between a firstposition generally aligned with or parallel to the first and secondlinkages' longitudinal axes 26A, 30A when the articulation assembly 18is in the straight configuration, as illustrated in FIG. 9, and to asecond, different position angularly oriented relative to the firstlinkage's longitudinal axis 26A when the articulation assembly 18 is inthe articulated configuration, as illustrated in FIG. 8. When thearticulation assembly 18 has been articulated to a maximum extent, suchas shown in FIG. 8, the first groove 62 a can allow the first linkagebar 32 a to pivot to be generally aligned with or parallel to the secondlinkage's longitudinal axis 30A. The maximum width W1 of the firstgroove 62 a can define the first range of motion of the first linkagebar 32 a relative to the shaft's axis 20A and hence also a maximumpossible degree value of the second angle A2 and a range of motion forthe second linkage 30 and the end effector 22. A person skilled in theart will appreciate that relative ranges of motions of the first andsecond linkage bars 32 a, 32 b about the second and third pivot points40, 46 can be achieved using the grooves 62 a, 62 b, 64 a, 64 b and/orin other ways, e.g., by providing linkages or linkage bars of differentrelative longitudinal lengths, by providing a stop element such as aprotrusion extending radially outward from a sidewall of one or both ofthe first and second linkages 26, 30 to prevent rotation of the linkagebars 32 a, 32 b beyond a certain point, etc. A person skilled in the artwill also appreciate that the device 10 can lack any or all of thegrooves 62 a, 62 b, 64 a, 64 b and thus not limit ranges of motion ofabout the second and third pivot points 40, 46.

Although the end effector 22 can be pivotally coupled to the secondlinkage's distal end such that it can pivot or articulate relative tothe second linkage 30, in the illustrated embodiment, a proximal end ofthe end effector 22 is non-pivotally coupled to a distal end of thesecond linkage 30, e.g., welded, snapped, or press fit thereon, whichcan allow the end effector 22 to articulate with the second linkage 30relative to the first linkage 26, the proximal shaft 24, and the handle12. The end effector 22 can additionally or alternatively be configuredto be movable relative to the second linkage 30, such as by beingrotatable relative thereto and/or by opening and closing the jaws 16 a,16 b, as discussed further below.

Although the end effector 22 is removably and replaceably coupled to thesecond linkage 30 in the device 10 of FIGS. 1-11 (the end effector 22 isomitted for clarity in FIGS. 1, 3-7 and 9) via the tool 19 proximallyinserted therein and moved distally beyond the second linkage's distalend, the end effector 22 can be removably and replaceably coupled to thesecond linkage 30 in any other way, such as by using any attachmentelement, e.g., complementary threads on the distal end of the shaft anda proximal end of the end effector, as will be appreciated by a personskilled in the art. In this way, different end effectors havingdifferent sizes and/or functions can be selectively attached to thedevice 10.

In one exemplary embodiment, illustrated in FIGS. 12-14, a surgicaldevice 10′ is provided that includes a proximal handle 12′ having anelongated, tubular shaft assembly 20′ extending distally therefrom. Thedevice 10′ can be configured and used similar to the device 10 of FIGS.1-11, but it can have an end effector fixedly attached to a distal endof the shaft assembly 20′. Although, as mentioned above, an end effectorcan be removably and replaceably coupled to a distal end of the shaftassembly 20′ using an attachment element. The end effector 22′ is shownin FIGS. 12-14 as a grasper including jaws 16 a, 16 b, a person skilledin the art will appreciate that any type of end effector can be coupledto the device 10′. Similar to that discussed herein regarding the device10, an articulation assembly 18′ can be configured to articulate theshaft assembly 20′ and angularly orient the end effector 22′.

Referring again to the embodiment of FIGS. 1-11, the device 10 caninclude an articulation actuator configured to articulate thearticulation assembly 18 at the first and second articulation joints 42,44 to form a compound angle. The articulation actuator can have avariety of configurations, but in the illustrated embodiment thearticulation actuator includes a rigid, linear or straight rod or bar66, generally referred to as an “actuator,” configured to move relativeto the proximal shaft 24 and the two linkages 26, 30 to bend thearticulation assembly 18 at the articulation joints 42, 44. Having arigid articulation actuator can facilitate smooth, controlledarticulation of the articulation assembly 18, although the articulationactuator can be flexible or partially flexible, e.g., a flexible cable.The actuator 66 can be solid or can have one or more hollow portions.

As shown in FIGS. 3 and 5-9, the actuator 66 can include a rigid rodhaving a distal end pivotally coupled to the second linkage 30 at afourth pivot point 68, and having a proximal end coupled to the device10 at a location proximal to the first articulation joint 42. Theactuator 66 can be pivotally coupled to the second linkage 30 in anyway, such as with a pin (not shown) inserted through respective holes 70formed in the distal end of the actuator 66 and in the second linkage30. As in the illustrated exemplary embodiment, the fourth pivot point68 can be located at a distal end of the second linkage 30, which canfacilitate controlled articulation and stabilization of the articulationassembly 18. The actuator's proximal end can be coupled to the device 10in any way and at any location such that movement of the knob 28 isconfigured to move the actuator 66. The proximal shaft 24 and linkages26, 30 can include a channel 72 formed therein that can be configured tomovably receive the actuator 66. The channel 72 can extendlongitudinally along a full or partial longitudinal length of any of theproximal shaft 24 and linkages 26, 30. Although the channel 72 extendsalong all of the proximal shaft 24 and the linkages 26, 30 in theillustrated embodiment, the channel 72 can extend along only a portionof the shaft assembly 20, e.g., only along the proximal shaft 24. Bybeing configured to seat the actuator 66 such that the actuator 66 sitsflush or sub-flush therein, the channel 72 can be configured to helpreduce a diameter of the shaft assembly 20, which can help easeinsertion and removal of the device's distal portion to and from apatient's body. Although the actuator 66 in the illustrated embodimentincludes a single rod, a person skilled in the art will appreciate thatthe actuator 66 can include multiple rods.

The actuator 66 can extend longitudinally parallel to the longitudinalaxis 20A when the articulation assembly 18 is not articulated, but alongitudinal axis 66A of the actuator 66 can be offset from and beparallel to the shaft's longitudinal axis 20A, as shown in FIG. 8.Having such an offset longitudinal axis 66A can reduce clutter in theshaft's lumen 34 and can facilitate articulation of the articulationassembly 18.

As mentioned above, the actuator 66 can be movable relative to theproximal shaft 24. As in the illustrated embodiment, the actuator 66 canbe movable longitudinally in proximal and distal directions parallel tothe shaft's longitudinal axis 20A to articulate the articulationassembly 18. In response to selective movement of the control knob 28,the actuator 66 can be configured to move longitudinally relative to theshaft's longitudinal axis 20A, e.g., along the actuator's longitudinalaxis 66A parallel to the shaft's longitudinal axis 20A. Moreparticularly, when the articulation assembly 18 is in the straightconfiguration, or when it is not maximally articulated in thearticulated configuration, longitudinal movement of the control knob 28along the shaft's longitudinal axis 20A in a proximal direction can movethe proximal shaft 24 longitudinally in a proximal direction over theshaft 36, and it can move the actuator 66 longitudinally in a proximaldirection, thereby pulling the distal end of the second linkage 30proximally to pivot the second linkage 30 relative to the actuator 66 atthe fourth pivot point 68. Although the actuator 66 and the secondlinkage 30 can be pivotally coupled together at the fourth pivot point38, the distal end of the second linkage 30 can be constrained tolongitudinal movement along the longitudinal axis 66A of the actuator66, and thus parallel to the shaft's longitudinal axis 20A, as theactuator 66 moves proximally and distally, as shown in FIG. 8. Suchconstrained movement can facilitate controlled, predictable movement ofthe second linkage 30 and hence of the end effector 22 coupled to thedistal end thereof. The pivotal movement of the second linkage 30 aboutthe fourth pivot point 68 can translate motion to the first pivot point38 at the first articulation joint 42 and to the second and third pivotpoints 40, 46 at the second articulation joint 44 to form a compoundangle.

The articulation assembly 18 can be similarly straightened using theactuator 66. When the articulation assembly 18 is in the articulatedconfiguration, longitudinal movement of the control knob 28 along theshaft's longitudinal axis 20A in a distal direction can distally,longitudinally move the proximal shaft 24 over the shaft 36 anddistally, longitudinally move the actuator 66, thereby pivoting thesecond linkage 30 relative to the actuator 66 at the fourth pivot point68. The pivotal movement of the second linkage 30 about the fourth pivotpoint 68 can translate motion to the first and second articulationjoints 42, 44 to decrease the compound angle, if not move thearticulation assembly 18 from the articulated configuration to thestraight configuration.

With the actuator 66 coupled to the distal end of the second linkage 30,the articulation assembly 18 can be bent in a distal-to-proximaldirection whether it is being increased or decreased in amount ofarticulation. In other words, longitudinal movement of the actuator 66can cause the second linkage 30 to pivot about the third pivot point 46prior to the first linkage 26 pivoting about the second pivot point 40,and it can cause the first linkage 26 to pivot about the second pivotpoint 40 prior to the first linkage 26 pivoting about the first pivotpoint 38.

The articulation actuator can optionally include a second actuator (notshown) configured to further facilitate articulation at the firstarticulation joint 42. The second actuator can have a distal end coupledto the proximal end of the first linkage 26, e.g., at a coupling point94 shown in FIG. 9, and it can have a proximal end coupled to the device10 at a location proximal to the first articulation joint 42. The secondactuator can be rigid and/or flexible, although in an exemplaryembodiment at least a distal portion of the second actuator can beflexible to allow the second actuator to bend at the first articulationjoint 42. In one exemplary embodiment, the second actuator can include aflexible cable extending parallel to the shaft's longitudinal axis 20Awithin the inner lumen 34, although the second actuator can bepositioned outside or partially outside the lumen 34. The secondactuator can be configured to be pulled in a proximal direction, such asby manipulating a lever or knob located at the handle 12 or at aproximal portion of the shaft assembly 20, to pull the first linkage 26at the coupling point 94 and help pivot the first linkage 26 about thefirst pivot point 38. The second actuator can be coupled to a dedicatedlever or knob or to the control knob 28 coupled to the actuator 66. Thecoupling point 94 can include a fixed coupling point, such as if thesecond actuator is welded or crimped to the first linkage 26, or can bea movable coupling point, such as with a cam slidably received in a slotformed in the first linkage 26. The coupling point 94 can belaterally/radially offset from the shaft's central longitudinal axis,which in the illustrated embodiment is shown as the longitudinal axis20A, by being near an outer edge of the first linkage 26, as shown inthe embodiment illustrated in FIG. 9. Such an offset position canfacilitate movement of the first linkage 26 and changing of the firstangle A1 when the second actuator is pulled.

The articulation actuator can be freely longitudinally movable to allowthe articulation assembly 18 to articulate any amount at any angles A1,A2. However, the control knob 28 can be configured to be manually heldin a fixed position to hold the articulation assembly 18 at a desiredcompound angle. The device 10 can include a lock configured tomechanically hold the articulation assembly 18 in a fixed position whenit is in the articulated configuration, which can ease manipulation ofthe device 10 when the articulation assembly 18 is articulated. As inthe illustrated embodiment, the device 10 can include a lock configuredto lock the articulation assembly 18 in a fixed position when it is at amaximum amount of articulation. The lock can have a variety ofconfigurations, as will be appreciated by a person skilled in the art.

In the illustrated embodiment, as shown in FIGS. 2, 3, and 10, the lockincludes holes 74 formed in a proximal end of the proximal shaft 24 andcomplementary pins 76 extending radially inward in a distal portion ofthe handle 12. The pins 76 can be spring-loaded or otherwise biased to aradially-inward position. Although holes 74 are shown formed in theproximal shaft 24, a person skilled in the art will appreciate that theproximal shaft 24 could instead have depressions or indentations formedtherein for receiving the pins 76. A person skilled in the art will alsoappreciate that although the lock includes two holes 74 and two pins 76,the device's lock can include any number of complementary holes andpins. When the proximal shaft 24 moves a sufficient proximal distancerelative to the handle 12, e.g., by pulling the control knob 28proximally, the holes 74 can align with the pins 76 such that the pins76 can snap into the holes 74. The engagement of the pins 76 within theholes 74 can hold the proximal shaft 24 in a fixed position relative tothe handle 12, thus maintaining the actuator 66 and a remainder of thearticulation assembly 18, e.g., the first and second linkages 26, 30, ina fixed position relative to the handle 12 and to each other. The lockcan be disengaged in any way, such as by moving the control knob 28distally to move the proximal shaft 24 distally and thereby snap thepins 76 out of the holes 74.

In addition to being longitudinally movable relative to the handle 12,the control knob 28 can be configured to rotate relative thereto torotate the shaft assembly 20 about the longitudinal axis 20A. If the endeffector 22 is attached to the shaft's distal end, as opposed to beingattached to an independent tool inserted through the device such as inthe embodiment illustrated in FIGS. 12-14, rotation of the shaftassembly 20 can also rotate the end effector 22. The control knob 28 canbe rotatable any amount in clockwise and/or counterclockwise directions.In the illustrated embodiment, the control knob 28 is rotatable 360° inboth clockwise and counterclockwise directions when the lock is notengaged, e.g., when the pins 76 are not engaged with the holes 74. Whenthe lock is engaged, the shaft assembly 20 can be prevented fromrotating. The proximal shaft 24 can include a plurality of holes 74arranged radially around its circumference or perimeter to allow thepins 76 to engage holes in the proximal shaft 24 when the proximal shaft24 is in a variety of rotated orientations.

The control knob 28 can include at least one gripping feature 80, shownin FIG. 1, formed thereon that can be configured to facilitatemanipulation of the control knob 28. The gripping feature 80 in theillustrated embodiment includes a plurality of finger depressions arounda perimeter of the control knob 28, but a person skilled in the art willappreciate that the control knob 28 can additionally or alternativelyinclude any one or more gripping features, e.g., a textured surface, afinger loop, a non-slip coating, etc.

As mentioned above, the device 10 includes a handle 12 having controlsconfigured to operate the end effector 22, e.g., to actuate and/orrotate the end effector 22. As in the embodiment illustrated in FIGS. 4,10, and 11, the handle 12 can include an actuator configured to actuatethe end effector 22, e.g., to open and close the jaws 16 a, 16 b. Theactuator can have a variety of sizes, shapes, and configurations, but asin the illustrated embodiment, it can include a translator element 88extending distally from the handle 12, through the shaft 36, and to theend effector 22. The translator element 88 can include an actuator,cable, wire, or rod, generally referred to as a “translator element,”shown in FIG. 10, having a proximal end coupled to an activator memberin the handle 12 and a distal end coupled to the end effector 22, with alength between the proximal and distal ends extending through the shaftassembly 20. The translator element 88 can include a singular element,e.g., one flexible cable, or it can include multiple elements, e.g., aproximal rigid rod and a distal flexible cable. In an exemplaryembodiment, at least a distal portion of the translator element 88 isflexible. By being flexible in at least a distal portion thereof, e.g.,in a portion extending through the articulation assembly 18, thetranslator element 88 can allow for actuation of the end effector 22 andarticulation of the articulation assembly 18 at the articulation joints42, 44. In the illustrated embodiment, the translator element 88includes a flexible cable. The flexible cable can be formed of anypliable material, e.g., an electroactive polymer, a shape memorymaterial such as Nitinol, etc., and can be attached to the handle 12 andthe end effector 22 in any way, e.g., crimped, tied, etc.

The activator member in the handle 12 can vary, but as in theillustrated embodiment, it can include a ratchet 86 driven by a thumbtrigger 84. The ratchet 86 can be configured to longitudinally translatethe translator element 88 parallel to the longitudinal axis 20A inresponse to manual pressure on the trigger 84. As the trigger 84 ispivoted relative to a pistol handle grip 82, the trigger 84 ratchets thetranslator element 88 proximally or distally through the shaft 36, theproximal shaft 24, and the two linkages 26, 30 to move the jaws 16 a, 16b, whether the articulation assembly 18 is articulated or not.

As mentioned above, and as will be appreciated by a person skilled inthe art, the handle 12 can include any rotating mechanism configured torotate the end effector 22 before and/or after the articulation assembly18 is articulated, such as a knob 90 as shown, a lever, a wired orwireless electronic control, etc. The knob 90 can include at least onegripping feature, e.g., raised ridges 92, configured to facilitatemanipulation of the knob 90. The knob 90 can be coupled to thetranslator element 88 and be configured to rotate the translator element88 a full 360° clockwise and/or counterclockwise to correspondinglyrotate the end effector 22 about the second linkage's longitudinal axis30A, which as mentioned above is the same as the shaft's longitudinalaxis 20A when the articulation assembly 18 is in the straightconfiguration. The knobs 28, 90 can thus allow for separate, relativerotation between the shaft assembly 20 and the end effector 22. Byextending through the shaft assembly 20 whether it is articulated ornot, the translator element 88 can allow the end effector 22 to berotated about the shaft's longitudinal axis 20A relative to the shaftassembly 20 with the articulation assembly 18 in either the straight orarticulated configuration.

In use, as shown in an exemplary embodiment in FIG. 15, one or moresurgical devices 10″ can be inserted through an opening 100 in tissue106 to access a body cavity 108 underlying the tissue 106 where thedevices 10″ can perform any type of surgical procedure. The devices 10″can generally each be configured and used similar to the device 10 ofFIGS. 1-11. As mentioned above, a person skilled in the art willappreciate that while the devices 10″ are shown in the illustratedembodiment in use in a laparoscopic procedure and inserted into the bodycavity 108, e.g., the abdominal cavity, through a multiple port accessdevice 102 positioned in the tissue opening 100, e.g., an incision atthe navel, any of the surgical devices disclosed herein can be used in avariety of surgical procedures and inserted into a patient's body in anynumber of ways. Prior to insertion of any instruments through themultiple port access device 102, insufflation can be provided through aninsufflation port, as will be appreciated by a person skilled in theart. A scoping device 104 can also be inserted through the multiple portaccess device 102 to provide visualization. Non-limiting examples of ascoping device include an endoscope, a laparoscope, and a colonoscope.

The multiple port access device 102 can include multiple instrumentopenings each configured to receive an instrument inserted therethrough.Each opening can have an associated sealing port that can be configuredto provide at least one instrument seal that forms a seal around aninstrument disposed therethrough, but otherwise does not form a sealwhen no instrument is disposed therethrough, at least one channel sealor zero-closure seal that seals a working channel created by the sealingport when no instrument is disposed therethrough, or a combinationinstrument seal and channel seal that is effective to both form a sealaround an instrument disposed therethrough and to form a seal in theworking channel when no instrument is disposed therethrough. Exemplaryembodiments of multiple port access devices are described in more detailin U.S. patent application Ser. No. 12/399,482 filed Mar. 6, 2009entitled “Methods And Devices For Providing Access Into A Body Cavity,”U.S. patent application Ser. No. 12/399,473 filed Mar. 6, 2009 entitled“Methods And Devices For Providing Access Into A Body Cavity,” U.S.patent application Ser. No. 12/512,542 filed Jul. 30, 2009 entitled“Methods And Devices For Providing Access Into A Body Cavity,” U.S.patent application Ser. No. 12/512,568 filed Jul. 30, 2009 entitled“Methods And Devices For Providing Access Into A Body Cavity,” U.S.patent application Ser. No. 12/399,633 filed Mar. 6, 2009 entitled“Methods And Devices For Providing Access Into A Body Cavity,” U.S.patent application Ser. No. 12/399,625 filed Mar. 6, 2009 entitled“Methods And Devices For Providing Access Into A Body Cavity,” U.S.patent application Ser. No. 12/399,547 filed Mar. 6, 2009 entitled“Surgical Access Devices And Methods Providing Seal Movement InPredefined Paths,” U.S. patent application Ser. No. 12/399,656 filedMar. 6, 2009 entitled “Surgical Access Devices And Methods ProvidingSeal Movement In Predefined Movement Regions,” and U.S. patentapplication Ser. No. 12/766,086 filed Apr. 23, 2010 entitled “MethodsAnd Devices For Accessing A Body Cavity,” which are hereby incorporatedby reference in their entireties.

The devices 10″ can be simultaneously or sequentially inserted throughthe multiple port access device 102 with the articulation assemblies 18″in straight configurations to position distal portions of the devices'proximal shafts 24″ within the body cavity 108. The proximal shafts 24″inserted through the multiple port access device 102 can each extendgenerally parallel to one another, e.g., have parallel longitudinalaxes. If one or both of the end effectors 22″ are not already coupled tothe devices 10″, e.g., if the end effector is located at a distal end ofa separate tool not yet inserted through the articulation assembly, thetool can be inserted therethrough to position the end effector(s) 22″distal to the articulation assembly or assemblies 18″. Such separatetools having end effectors at distal ends thereof can be inserted afterthe articulation assemblies 18″ have been articulated, but it can beeasier and faster to articulate the tools with the articulationassemblies 18″ rather than navigate the tools throughpreviously-articulated articulation assemblies 18″. After the distalportions of the proximal shafts 24″ and the end effector 22″ have beenpositioned within the body cavity 108, control knobs (not shown) of thedevices 10″ can be manipulated, simultaneously or sequentially, to movethe articulation assemblies 18″ from straight configurations toarticulated configurations and to allow the end effectors 22″ to bebrought together in a non-interfering, cooperative, facing relationshipand to be within a viewing range 110 of the scoping device 104, asillustrated in FIG. 16. In this way, the proximal shafts 24″ of thedevices 10″ can each extend generally parallel to one another while thearticulation assemblies 18″ are articulated such that the end effectors22″ can be angularly oriented toward a same target tissue and/or towardone another in a cooperative relationship. The devices' handles (notshown) coupled to proximal ends of the proximal shafts 24″ can thus bemore easily manipulated outside the body, e.g., with a reduced“chopstick” effect. The devices' articulation assemblies 18″ can bearticulated any amount, including not at all, same or different from oneanother, and can be selectively adjusted during the surgical procedureto form larger or smaller compound angles as desired. The devices'shafts can also be rotated relative to the devices' handles, the endeffectors 22″ can be rotated relative to their respective device shafts,and the end effectors' jaws 16″ can be opened and closed. The devices10″ can thus allow the articulation assemblies 18″ to be easily insertedinto a body in straight configurations through a single, relativelysmall opening 100 and be subsequently articulated to optimally positionthe end effectors 22″ relative to the surgical site, to each other, tothe scoping device 104, and to any other tools within the body cavity108. Because the device 10″ can be articulated, its end effector 22″ canbe positioned at an angle with respect to a remainder of the proximalshaft 24″ thereof, triangulation and visualization can be improved. Inother words, even though the devices 10″ and the scoping device 104 areinserted through a common incision, it is still possible to see the endeffectors 22″ of the devices 10″ and to bring the end effectors 22″ ofthe two instruments devices 10″ together in a facing relationship at asingle point within the body cavity 108.

The devices 10″ can also be easily removed from the patient's body bymoving the articulation assemblies 18″ from articulated configurationsto straight configurations. The multiple port access device 102 can beconfigured to allow further adjustment of instruments insertedtherethrough, such as by allowing collective rotation of the instrumentsaround a central axis of the multiple port access device 102.

A proximal housing portion of the multiple port access device 102 can beconfigured to be removable from a distal retractor portion of themultiple port access device 102. Thus, at any point before, during, orafter a surgical procedure, the proximal housing portion can in full orpart be released from the distal retractor portion, and the distalretractor portion can be removed from the tissue 106. With the proximalhousing portion of the multiple port access device 102 disengaged fromthe distal retractor portion and with the distal retractor portion stillpositioned in the tissue opening 100, a working channel of the distalretractor portion can provide access to the body cavity 108 underlyingthe tissue 106. One or more of the devices 10″ and/or other surgicalinstruments can be advanced through the working channel, such as a wasteremoval bag configured to hold waste material, e.g., dissected tissue,excess fluid, etc., from the body cavity 108. The bag can be introducedinto the body cavity 108 through the distal retractor portion's workingchannel or other access port. A person skilled in the art willappreciate that one or more surgical instruments can be advanced throughthe distal retractor portion's working channel before and/or after theproximal housing portion has been attached to the distal retractorportion. A surgical drape can optionally be placed over the distalretractor portion and the tissue opening 100 during removal of thedistal retractor portion to help reduce dispersion of bodily fluidoutside the surgical space.

The devices disclosed herein can be designed to be disposed of after asingle use, or they can be designed to be used multiple times. In eithercase, however, the device can be reconditioned for reuse after at leastone use. Reconditioning can include any combination of the steps ofdisassembly of the device, followed by cleaning or replacement ofparticular pieces, and subsequent reassembly. In particular, the devicecan be disassembled, and any number of the particular pieces or parts ofthe device can be selectively replaced or removed in any combination,e.g., an end effector, a proximal housing portion of a surgical accessdevice, an end effector, etc. Upon cleaning and/or replacement ofparticular parts, the device can be reassembled for subsequent useeither at a reconditioning facility, or by a surgical team immediatelyprior to a surgical procedure. Those skilled in the art will appreciatethat reconditioning of a device can utilize a variety of techniques fordisassembly, cleaning/replacement, and reassembly. Use of suchtechniques, and the resulting reconditioned device, are all within thescope of the present application.

Preferably, the invention described herein will be processed beforesurgery. First, a new or used instrument is obtained and if necessarycleaned. The instrument can then be sterilized. In one sterilizationtechnique, the instrument is placed in a closed and sealed container,such as a plastic or TYVEK bag. The container and instrument are thenplaced in a field of radiation that can penetrate the container, such asgamma radiation, x-rays, or high-energy electrons. The radiation killsbacteria on the instrument and in the container. The sterilizedinstrument can then be stored in the sterile container. The sealedcontainer keeps the instrument sterile until it is opened in the medicalfacility.

One skilled in the art will appreciate further features and advantagesof the invention based on the above-described embodiments. Accordingly,the invention is not to be limited by what has been particularly shownand described, except as indicated by the appended claims. Allpublications and references cited herein are expressly incorporatedherein by reference in their entirety.

What is claimed is:
 1. A method for laparoscopic surgery, comprising:inserting an end effector of a tool into a body cavity, the tool havinga first linkage coupled to an elongate shaft at a first joint, a secondlinkage having a proximal end coupled to the first linkage at a secondjoint that is movable away from a central longitudinal axis of theelongate shaft, and an end effector coupled to and inserted through adistal end of the second linkage; and actuating the tool to cause thedistal end of the second linkage to move parallel to the centrallongitudinal axis of the elongate shaft.
 2. The method of claim 1,wherein actuating the tool causes the second joint to move away from thecentral longitudinal axis of the elongate shaft.
 3. The method of claim1, wherein actuating the tool causes the first linkage and the secondlinkage to move from a first position in which the linkages are co-axialwith one another to a second position in which the linkages form anangle with each other such that they are no longer co-axial.
 4. Themethod of claim 1, wherein actuating the tool causes an actuator to movelongitudinally relative to the central longitudinal axis.
 5. The methodof claim 1, wherein actuating the tool causes the second linkage topivot about a pivot point at which an actuator is coupled to the distalend of the second linkage.
 6. The method of claim 1, wherein actuatingthe tool causes the second joint to move radially away from the centrallongitudinal axis of the elongate shaft.
 7. The method of claim 1,further comprising locking the first linkage, second linkage, and endeffector in a fixed position relative to the elongate shaft.
 8. Themethod of claim 1, further comprising actuating the tool to move opposedjaws of the end effector of the tool between a closed position and anopen position.
 9. A method for laparoscopic surgery, comprising:inserting a first tool through a first port formed in a housing disposedwithin tissue to position a first end effector on a distal end of thefirst tool within a body cavity; inserting a second tool through asecond port formed in the housing to position a second end effector on adistal end of the second tool within the body cavity; longitudinallymoving a first actuator extending along a first elongate shaft of thefirst tool to cause a first linkage and a second linkage on the firstend effector to form a compound angle; and longitudinally moving asecond actuator extending along a second elongate shaft of the secondtool to cause a third linkage and a fourth linkage on the second endeffector to form a compound angle; wherein, when proximal portions ofeach of the first and second tools are substantially parallel, actuatingthe first and second tools causes the first and second end effectors tobe oriented toward one another without causing the first and second endeffectors to intersect.
 10. The method of claim 9, further comprisingengaging a lock of at least one of the first and second tools tomaintain the compound angle of the one of the first and second tools ina fixed position.
 11. The method of claim 9, further comprisingactuating the first tool to move opposed jaws of the first end effectorbetween a closed position and an open position, wherein the formedcompound angle of the first tool remains fixed during actuation of thefirst tool.
 12. The method of claim 9, wherein actuating the first toolcauses the first end effector to pivot about a first pivot point along afirst longitudinal axis of the first elongate shaft, and actuating thesecond tool causes the second end effector to pivot about a second pivotpoint along a second longitudinal axis of the second elongate shaft. 13.The method of claim 9, wherein a distal end of the second linkage of thefirst tool is constrained to movement along an axis of an actuator thatcauses the first end effector to form a compound angle, and a distal endof the fourth linkage of the second tool is constrained to movementalong an axis of an actuator that causes the second end effector to forma compound angle.
 14. The method of claim 9, wherein the first elongateshaft and at least a portion of the first and second linkages includes achannel formed therein that movably receives the first actuator.